Increasing pregnancy-related use of prescribed opioid analgesics

Maternal opioid use during pregnancy and the risk of neonatal opioid withdrawal syndrome in the offspring

INTRODUCTION

Neonatal opioid withdrawal syndrome (NOWS) is caused by sudden cessation from in utero exposure to opioids. The indications for opioid use during pregnancy are diverse including medication for opioid use disorder and analgesia. The opioid dose typically depends on the indication, with higher doses used for medication for opioid use disorder and lower doses used for analgesia. The aim of this study was to investigate the relationship between maternal opioid dose during pregnancy and the risk of NOWS.

MATERIAL AND METHODS

We conducted a historical multicenter cohort study of neonates prenatally exposed to opioids in Eastern Denmark during a six-year period from 2013 to 2018. The data was extracted from reviewing the individual's medical record(s), which were identified through a search of the Danish National Patient Register. Four groups (quartiles) according to maternal opioid dose during the last four weeks prior to delivery were compared. Unadjusted and adjusted logistic regression analyses were conducted to examine the risk of NOWS while controlling for relevant covariates.

RESULTS

A total of 130 in utero opioid exposed neonates were included. The majority of the pregnant patients (88%) were treated with opioids for analgesic purposes. Overall, 52% of neonates developed NOWS. The cumulative incidence of NOWS was 21%, 28%, 67% and 91% at maternal average daily dose of morphine milligram equivalent during the last four weeks prior to delivery of 0.7-14 (group I), 14.3-38.6 (group II), 40-90 (group III) and 90.9-1440 (group IV), respectively. Compared to group I the adjusted odds (aOR) of NOWS increased significantly in group III (aOR 10.6 [2.9-39.1]) and group IV (aOR 37.8 [7.6-188.2]) but not in group II (aOR 1.5 [0.4-5.2]). No cases of NOWS were reported at maternal dose less than an average daily dose of five morphine milligram equivalent during the last four weeks prior to delivery. No significant changes in the incidence of NOWS were observed between 2013 and 2018.

CONCLUSIONS

The odds of neonatal opioid withdrawal syndrome increased significantly as the maternal average daily dose of morphine milligram equivalent during the last four weeks prior to delivery surpassed 40.

Risk of Death at 1 Year Following Postpartum Opioid Exposure

OBJECTIVE

Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births.

METHODS

In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis.

RESULTS

Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings.

CONCLUSION

Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers.

KEY POINTS

· Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..

Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding

OBJECTIVE

To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will improve patient care.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All health care providers who care for pregnant and/or post-partum women and their newborns.

TWEETABLE ABSTRACT

Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement

OBJECTIF

Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum.

POPULATION CIBLE

Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Neonatal opioid toxicity: opioid withdrawal (abstinence) syndrome with emphasis on pharmacogenomics and respiratory depression

The increasing use of opioids in pregnant women has led to an alarming rise in the number of cases of neonates with drug-induced withdrawal symptoms known as neonatal opioid withdrawal syndrome (NOWS). NOWS is a toxic heterogeneous condition with many neurologic, autonomic, and gastrointestinal symptoms including poor feeding, irritability, tachycardia, hypertension, respiratory defects, tremors, hyperthermia, and weight loss. Paradoxically, for the management of NOWS, low doses of morphine, methadone, or buprenorphine are administered. NOWS is a polygenic disorder supported by studies of genomic variation in opioid-related genes. Single-nucleotide polymorphisms (SNPs) in CYP2B6 are associated with variations in NOWS infant responses to methadone and SNPs in the OPRM1, ABCB1, and COMT genes are associated with need for treatment and length of hospital stay. Epigenetic gene changes showing higher methylation levels in infants and mothers have been associated with more pharmacologic treatment in the case of newborns, and for mothers, longer infant hospital stays. Respiratory disturbances associated with NOWS are not well characterized. Little is known about the effects of opioids on developing neonatal respiratory control and respiratory distress (RD), a potential problem for survival of the neonate. In a rat model to test the effect of maternal opioids on the developing respiratory network and neonatal breathing, maternal-derived methadone increased apneas and lessened RD in neonates at postnatal (P) days P0 and P1. From P3, breathing normalized with age suggesting reorganization of respiratory rhythm-generating circuits at a time when the preBötC becomes the dominant inspiratory rhythm generator. In medullary slices containing the preBötC, maternal opioid treatment plus exposure to exogenous opioids showed respiratory activity was maintained in younger but not older neonates. Thus, maternal opioids blunt centrally controlled respiratory frequency responses to exogenous opioids in an age-dependent manner. In the absence of maternal opioid treatment, exogenous opioids abolished burst frequencies at all ages. Prenatal opioid exposure in children stunts growth rate and development while studies of behavior and cognitive ability reveal poor performances. In adults, high rates of attention deficit disorder, hyperactivity, substance abuse, and poor performances in intelligence and memory tests have been reported.

Reproductive and developmental toxicity assessments of LPM3480392, a novel mu opioid receptor biased agonist in rats

Opioids remain the most powerful analgesics for moderate to severe pain but their clinical use, misuse and abuse has been an alarming medical problem, especially for those users at child-bearing age. Mu-opioid receptor (MOR) biased agonists have been suggested as superior alternatives with better therapeutic ratios. We recently discovered and characterized a novel MOR biased agonist, LPM3480392, which demonstrates robust analgesic effect, favorable pharmacokinetic performance, and mild respiratory suppression in vivo. To understand the safety profile of LPM3480392 on the reproductive system and embryonic development, this study evaluated the effects of LPM3480392 on the fertility and early embryonic development, embryo-fetal development, and pre- and postnatal development in rats. Results showed that LPM3480392 had mild effects on parental male and female animals, accompanied by subtle early embryonic loss and delayed ossification of fetal development during organogenesis period. In addition, although minor effects were found on normal developmental milestones and behaviors in the pups, there was no evidence of malformed effect. In conclusion, these results suggest that LPM3480392 has a favorable safety profile with only minor effects on the reproductive and developmental outcomes in animals, which support the development of LPM3480392 as a novel analgesic.

Nutritional Status Differs by Prescription Opioid Use among Women of Reproductive Age: NHANES 1999-2018

Prescription opioid use among pregnant women has increased in recent years. Prenatal exposure to opioids and poor nutrition can both negatively impact maternal-fetal outcomes. The objective of this study was to characterize the nutrition and health status of reproductive-age women taking prescription opioids, compared to women not taking opioids. Using NHANES 1999-2018 data, non-pregnant women aged 20-44 years were classified as taking a prescription opioid in the last 30 days (n = 404) or unexposed controls (n = 7234). Differences in anthropometric, cardiovascular, hematologic, and micronutrient status indicators between opioid-exposed and unexposed women were examined. Opioid-exposed women were older, had lower income and education, and were more likely to be non-Hispanic White, to smoke, and to have chronic health conditions compared to unexposed women. In unadjusted analyses, several nutrition and health markers were significantly different between opioid exposure groups. After controlling for covariates, women taking opioids had higher odds of Class II (OR = 1.6, 95% CI = 1.1-2.3) or III obesity (OR = 1.6, 95% CI = 1.1-2.5), and lower levels of serum folate, iron, and transferrin saturation. Reproductive-age women taking prescription opioids may be at risk for poorer nutritional and cardiometabolic health. Future research is needed to explore whether nutritional status impacts maternal-fetal outcomes for women exposed to opioids during pregnancy.

Prenatal methadone exposure selectively alters protein expression in primary motor cortex: Implications for synaptic function

As problematic opioid use has reached epidemic levels over the past 2 decades, the annual prevalence of opioid use disorder (OUD) in pregnant women has also increased 333%. Yet, how opioids affect the developing brain of offspring from mothers experiencing OUD remains understudied and not fully understood. Animal models of prenatal opioid exposure have discovered many deficits in the offspring of prenatal opioid exposed mothers, such as delays in the development of sensorimotor function and long-term locomotive hyperactivity. In attempt to further understand these deficits and link them with protein changes driven by prenatal opioid exposure, we used a mouse model of prenatal methadone exposure (PME) and preformed an unbiased multi-omic analysis across many sensoriomotor brain regions known to interact with opioid exposure. The effects of PME exposure on the primary motor cortex (M1), primary somatosensory cortex (S1), the dorsomedial striatum (DMS), and dorsolateral striatum (DLS) were assessed using quantitative proteomics and phosphoproteomics. PME drove many changes in protein and phosphopeptide abundance across all brain regions sampled. Gene and gene ontology enrichments were used to assess how protein and phosphopeptide changes in each brain region were altered. Our findings showed that M1 was uniquely affected by PME in comparison to other brain regions. PME uniquely drove changes in M1 glutamatergic synapses and synaptic function. Immunohistochemical analysis also identified anatomical differences in M1 for upregulating the density of glutamatergic and downregulating the density of GABAergic synapses due to PME. Lastly, comparisons between M1 and non-M1 multi-omics revealed conserved brain wide changes in phosphopeptides associated with synaptic activity and assembly, but only specific protein changes in synapse activity and assembly were represented in M1. Together, our studies show that lasting changes in synaptic function driven by PME are largely represented by protein and anatomical changes in M1, which may serve as a starting point for future experimental and translational interventions that aim to reverse the adverse effects of PME on offspring.

Opioid Use in Pregnancy: A Review

Importance

The use and misuse of opioids in pregnancy have been increasing and are a major public health issue. Opioid use in pregnancy and during lactation has been associated with increased maternal and neonatal morbidity and mortality.

Objective

This review aims to summarize the existing literature and current recommendations for opioid use while pregnant or lactating.

Evidence Acquisition

A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "opioids," "opioid maintenance therapy," "opioid use disorder," "suboxone," "buprenorphine," "methadone," "medication for opioid use disorder," "fetal outcomes," "perinatal outcomes," "pregnancy," "lactation," and "neonatal abstinence syndrome."

Results

Available studies on opioid use in pregnancy and during lactation were reviewed and support association with increased odds of maternal death, placental insufficiency, cardiac arrest, preterm birth, neonatal intensive care unit admission, low birth weight, and small for gestational age infants. Studies were also reviewed on pharmacotherapy options in pregnancy and promising prenatal care models.

Conclusion and Relevance

There is a critical need for research on the effects of opioid use and related pharmacotherapy options in pregnancy. Once the adverse perinatal effects of opioid exposure are identified and well-characterized, patient education, intervention, and antenatal surveillance can be developed to predict and mitigate its impact on maternal and fetal health.

The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee

INTRODUCTION

This study analyzed the association between the implementation of the Tennessee Fetal Assault Law (TFAL), which allowed prosecutors to incarcerate people who used substances during pregnancy, and out-of-state births among residents of Tennessee.

METHODS

The main data source is vital records on singleton births in hospitals to people aged 15-44 years during the period January 2010 to June 2016. We include data from 33 states and the District of Columbia where birth certificate data are comparable over this time period. The statistical significance of the difference in outcomes observed before and after TFAL implementation was tested using a difference-in-differences analysis between Tennessee and the comparison group.

RESULTS

After TFAL implementation, the odds of having an out-of-state birth increased by 13% for residents of Tennessee (odds ratio, 1.13; 95% confidence interval, 1.09-1.16) relative to residents of the comparison states. When we adopted different thresholds for travel distances to the birth hospital, the odds of residents of Tennessee having an out-of-state birth more than 75 miles away increased by 17% (odds ratio, 1.17; 95% confidence interval, 1.13-1.21) after TFAL implementation.

CONCLUSION

The results of this study suggest that the implementation of a policy allowing incarceration of people who use substances during pregnancy is associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.

Epidemiology of opioid use in pregnancy

The world has been experiencing an opioid epidemic for over 20 years, and rates of use and overdose among women, including during pregnancy, have risen markedly. Women receive more prescriptions for opioids compared to men. Data suggest that 20% of women filled at least one prescription for an opioid during their pregnancy, and the prevalence of prenatal exposure averaged 14%. Opioid use by women, especially during pregnancy and while breastfeeding, and management and treatment is complex for healthcare providers, especially related to methadone treatment, pain management during labour, neonatal opioid withdrawal syndrome, nutritional issues and maternal withdrawal. Opioid use during pregnancy has been associated with maternal, foetal and infant complications, and overdose has become a leading cause of death in post-partum women in some countries. Universal screening for opioid use disorder (OUD) is recommended in pregnancy, and prevention and treatment programs that meet the specific needs of women are important to understand and consider as the world continues to try to anticipate and respond to the realities of the opioid epidemic.

False-positive Fentanyl Urine Detection After Initiation of Labetalol Treatment for Hypertension in Pregnancy: A Case Report

BACKGROUND

Labetalol hydrochloride (LH) is a pharmacologic treatment for hypertensive disease (HD) in pregnancy. However, for pregnant persons with substance use disorders (SUDs), LH may interfere with urine drug testing.

CASE SUMMARY

We present 3 pregnant or postpregnant persons with SUDs who experienced presumptive positive urine immunoassays for fentanyl while prescribed LH for perinatal HD.

DISCUSSION

Labetalol hydrochloride treatment for HD in pregnancy can result in presumptive positive urine immunoassays for fentanyl. Unrecognized or misinterpreted, this phenomenon can lead to significant consequences for pregnant and postpartum persons with co-occurring substance use and hypertensive disorders. Clinicians caring for pregnant persons with SUDs must be aware of this phenomenon and its sequelae when ordering and interpreting urine immunoassays for fentanyl.

A population-based descriptive study of neonatal abstinence syndrome using hospital discharge and birth certificate data

BACKGROUND

Neonatal abstinence syndrome (NAS), largely a consequence of prenatal opioid exposure, results in substantial morbidity. Population-based studies of NAS going beyond Medicaid populations and hospital discharge data (HDD) alone are limited. Using statewide Tennessee (TN) HDD and birth certificate (BC) data, we examined trends and evaluated maternal and infant factors associated with NAS.

METHODS

We conducted a population-based descriptive study during 2013-2017 in TN. NAS infants were identified with International Classification of Diseases (ICD)-9-Clinical Modification (CM) and ICD-10-CM codes in HDD and linked to BC data using iterative deterministic matching algorithms. Descriptive analyses were conducted for infant and maternal factors (exposures) by NAS (outcome). Multivariable logistic regression models were used to estimate adjusted ORs and 95% CIs.

RESULTS

NAS incidence increased from 13.4 to 15.4 per 1,000 live births between 2013-2017 (15% increase; ptrend<0.001), but remained stable in 2017. In adjusted models, maternal factors associated with reduced odds of NAS included breastfeeding (OR:0.55, 95%CI:0.52-0.59) and prenatal care (OR:0.36, 95%CI:0.32-0.41). Smoking, preterm birth and lower birthweight were associated with increased odds of NAS.

CONCLUSIONS

This study highlights the value of utilizing surveillance data to monitor trends and correlates of NAS to inform prevention efforts and targeting of public health resources.

Current research in pathophysiology of opioid-induced respiratory depression, neonatal opioid withdrawal syndrome, and neonatal antidepressant exposure syndrome

Respiratory depression (RD) is the primary cause of death due to opioids. Opioids bind to mu (µ)-opioid receptors (MORs) encoded by the MOR gene Oprm1, widely expressed in the central and peripheral nervous systems including centers that modulate breathing. Respiratory centers are located throughout the brainstem. Experiments with Oprm1-deleted knockout (KO) mice undertaken to determine which sites are necessary for the induction of opioid-induced respiratory depression (OIRD) showed that the pre-Bötzinger complex (preBötC) and the pontine Kölliker-Fuse nucleus (KF) contribute equally to OIRD but RD was not totally eliminated. Morphine showed a differential influence on preBötC and KF neurons - low doses attenuated RD following deletion of MORs from preBötC neurons and an increase in apneas after high doses whereas deletion of MORs from KF neurons but not the preBötC attenuated RD at both high and low doses. In other KO mice studies, morphine administration after deletion of Oprm1 from both the preBötC and the KF/PBN neurons, led to the conclusion that both respiratory centres contribute to OIRD but the preBötC predominates. MOR-mediated post-synaptic activation of GIRK potassium channels has been implicated as a cause of OIRD. A complementary mechanism in the preBötC involving KCNQ potassium channels independent of MOR signaling has been described. Recent experiments in rats showing that morphine depresses normal, but not gasping breathing, cast doubt on the belief that eupnea, sighs, and gasps, are under the control of preBötC neurons. Methadone, administered to alleviate symptoms of neonatal opioid withdrawal syndrome (NOWES), desensitized rats to OIRD. Protection lost between postnatal days 1 and 2 coincides with the preBötC becoming the dominant generator of respiratory rhythm. Neonatal antidepressant exposure syndrome (NADES) and serotonin toxicity (ST) show similarities including RD. Enzyme CYP2D6 involved in opioid detoxification is polymorphic. Individuals of different CYP2D6 genotype may show increased, decreased, or no enzyme activity, contributing to the variability of patient responses to different opioids and OIRD.

Emergency Department Utilization for Substance Use Disorder During Pregnancy and Postpartum in the United States (2006-2016)

OBJECTIVES

We aimed to better understand emergency department (ED) use, admission patterns, and demographics for substance use disorder in pregnancy and postpartum (SUDPP).

METHODS

In this longitudinal study, the United States Nationwide Emergency Department Sample was queried for all ED visits by 15- to 50-year-old women with a primary diagnosis defined by International Classification of Diseases, 9th or 10th edition Clinical Modification, codes of SUDPP between 2006 and 2016. Patterns of ED visit counts, rates, admissions, and ED charges were analyzed.

RESULTS

Annual national estimated ED visits for SUDPP increased from 2,919 to 9,497 between 2006 and 2016 (a 12.4% annual average percentage change), whereas admission rates decreased (from 41.9% to 32.0%). ED visits were more frequent among women who were 20-29 years old, using Medicaid insurance, in the lowest income quartile, living in the South, and in metropolitan areas. Compared with the proportion of ED visits, 15- to 19-year-olds had significantly lower admission rates, whereas women with Medicaid and in the lowest income quartile had higher admission rates (p < .001). Opioid use, tobacco use, and mental health disorders were most commonly associated with SUDPP. The ED average inflation-adjusted charges for SUDPP increased from $1,486 to $3,085 between 2006 and 2016 (7.1% annual average percentage change; p < .001), yielding total annual charges of $4.02 million and $28.53 million.

CONCLUSIONS

Despite the decrease in admissions, the number and charges for ED visits for SUDPP increased substantially between 2006 and 2016. These increasing numbers suggest a continuous need to implement preventive public health measures and provide adequate outpatient care for this condition in this population specifically.

Opioid exposure during pregnancy and the risk of congenital malformation: a meta-analysis of cohort studies

BACKGROUND

Opioid exposure during pregnancy has increased alarmingly in recent decades. However, the association between prenatal opioid exposure and congenital malformation risk has still been controversial. We aim to assess the association between opioid exposure during pregnancy and the risk of congenital malformations.

METHOD

PubMed, Embase, and Cochrane library of clinical trials were systematically searched to September 13th, 2021. Cohort studies reporting risk of congenital malformation after opioid exposure compared with non-exposure during pregnancy were included. Risk of studies was appraised with the ROBINS-I tool. Meta-analysis was conducted using the random-effects model. Subgroup analyses were conducted for the primary outcome based on indication, exposed period, whether adjusted data was used, and risk of bias assessment. Meta-regression was performed to evaluate the relation of publication year.

MAIN RESULTS

Eighteen cohort studies with 7,077,709 patients were included. The results showed a significant increase in the risk of overall congenital malformation (RR = 1.30, 95%CI: 1.11-1.53), major malformation (RR = 1.57, 95%CI:1.11-2.22), central nervous system malformation (RR = 1.36, 95% CI:1.19-1.55), and limb malformation (RR = 2.27, 95%CI:1.29-4.02) with opioid exposure during pregnancy. However, the predictive interval conveyed a different result on overall congenital malformation (95%PI: 0.82-2.09) and major malformation (95%PI: 0.82-2.09). No association between opioid exposure and overall congenital malformation in the first trimester (RR = 1.12, 95%CI:0.97-1.31) and prescribed for analgesic or antitussive treatment (RR = 1.03, 95%CI:0.94-1.13) were observed. In subgroups that study provided data adjusted for confounders (RR = 1.06, 95%CI:0.93-1.20) or identified moderate or serious risk of bias (RR = 1.00, 95%Cl: 0.85-1.16; RR = 1.21, 95%Cl: 1.60-2.68), no association was found.

CONCLUSION

Opioid exposed in the first trimester or prescribed for analgesic or antitussive treatment did not increase the risk of overall congenital malformation. The findings should be discussed in caution considering the situation of individual patients and weigh out its potential risk of congenital malformation.

TRIAL REGISTRATION

Registration number: CRD42021279445 .

Trends, patterns, and maternal characteristics of opioid prescribing during pregnancy in a large population-based cohort study

BACKGROUND

Opioid use during pregnancy has been associated with adverse maternal and infant health outcomes. Prescription drug monitoring programs (PDMP) provide a population-based source of prescription data. We linked statewide PDMP and birth certificate data in Tennessee (TN) to determine patterns of prescription opioid and benzodiazepine use during pregnancy.

METHODS

We constructed a cohort of 311,217 live singleton births from 2013 to 2016 with prescription history from 90 days before pregnancy to birth. Descriptive statistics were used to describe opioid prescription patterns during pregnancy overall, by maternal characteristics and by year. Multivariable logistic regression models estimated adjusted odds ratios and 95% confidence intervals for factors associated with prescription use.

RESULTS

The prevalence of prescription use during pregnancy was 14.1% for opioid analgesics, 1.6% buprenorphine for medication-assisted treatment, and 2.6% for benzodiazepines. The prevalence of opioid analgesic use decreased from 16.6% (2013) to 11.8% (2016) (ptrend< 0.001). About 25% used for > 7 and 9.7% for > 30 days' supply. The most common types were hydrocodone (9.3%), codeine (3.4%), and oxycodone (2.9%). In adjusted models, lower education, lower income, pre-pregnancy obesity and smoking during pregnancy were associated with increased odds of any opioid and opioid analgesic use.

CONCLUSION(S)

Despite the encouraging trend of decreasing use of prescription opioid analgesics, the overall prevalence remained close to 12% with many women using for long durations. Use was associated with lower socioeconomic status, obesity, and prenatal smoking. Findings highlight the need for maternal education and resources, and provider support for implementation of evidence-based care.

Ischemic Placental Disease, Preterm Delivery, and Their Association With Opioid Use During Pregnancy

Opioids affect placental development and function in animal models, but human data on their association with ischemic placental disease are limited. Using a cohort of pregnant women in the US nationwide Medicaid Analytic eXtract (2000-2014), we compared women with ≥2 opioid dispensings in pregnancy with unexposed women. Given an uncertain etiologically relevant window, we assessed exposure occurring in early pregnancy, late and not early pregnancy, and both early and late pregnancy. For placental abruption, preterm delivery, small for gestational age (SGA), and preeclampsia, we estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) using Cox proportional hazard models adjusting for demographic factors, indications/comorbidities, and medications. Among 1,833,871 eligible pregnancies, ≥2 opioid dispensings were filled in 6.5%. We observed an early exposure aHR of 1.34 (95% CI: 1.26, 1.43) for placental abruption, 1.21 (95% CI: 1.18, 1.23) for preterm delivery, 1.13 (95% CI: 1.09, 1.17) for SGA, and 0.95 (0.91, 0.98) for preeclampsia. Estimates for late exposure were attenuated. Early and late exposure was associated with higher aHRs for placental abruption, 1.62 (95% CI: 1.47, 1.78); preterm delivery, 1.37 (95% CI: 1.33, 1.42); and SGA, 1.26 (95% CI: 1.19, 1.33); but not preeclampsia, 0.99 (95% CI: 0.93, 1.05). Prescription opioids may modestly increase risk of placental abruption, preterm birth and SGA, but they do not appear to be associated with preeclampsia.

Does Maternal Incarceration Impact Infants with Neonatal Abstinence Syndrome?

OBJECTIVES

Opioid exposed infants born to incarcerated women represent a vulnerable and understudied subset of infants with neonatal abstinence syndrome (NAS). The impact of maternal incarceration on length of stay (LOS) for infants with NAS is unknown. We hypothesized that infants with NAS born to incarcerated women have longer hospitalizations compared to infants with NAS born to non-incarcerated women.

METHODS

This is a retrospective cohort study of infants with NAS born between 2011 and 2018 at the primary delivery site for Connecticut's only women's prison. Opioid exposed infants were assessed by Finnegan Scores for withdrawal and received morphine as a first line agent and phenobarbital as a second line agent. LOS was compared using Poisson regression.

RESULTS

Of 206 infants identified, 166 were included in the analysis, with 28 born to incarcerated women and 138 to non-incarcerated women. Incarcerated women were more likely to report prenatal alcohol use, 14.3% vs 2.2% p = 0.016 and benzodiazepine use 21.4% vs 7.3% p = 0.032. Infants of incarcerated women were less likely to be fed breast milk at discharge, 3.6% vs 37% p < 0.001. Adjusted mean LOS was longer among infants born to incarcerated women, 18.5 vs 16.6 days (p = 0.009).

CONCLUSIONS FOR PRACTICE

Infants with NAS born to incarcerated women in Connecticut had longer LOS, lower rates of being fed breast milk, and different prenatal substance exposures than infants with NAS born to non-incarcerated women. Supporting the maternal-infant dyad until infant discharge may mitigate the potential negative impact of maternal incarceration on the care of infants with NAS.

Prevalence and duration of prescribed opioid use during pregnancy: a cohort study from the Quebec Pregnancy Cohort

Background

Recent studies show a rapid growth among pregnant women using high potency opioids for common pain management during their pregnancy. No study has examined the duration of treatment among strong opioid users and weak opioid users during pregnancy. We aimed to investigate the prevalence of prescribed opioid use during pregnancy, in Quebec; and to compare the duration of opioid treatment between strong opioid users and weak opioid users.

Methods

Using the Quebec Pregnancy Cohort (1998–2015), we included all pregnancies covered by the Quebec Public Prescription Drug Insurance Program. Opioid exposure was defined as filled at least one prescription for any opioid during pregnancy or before pregnancy but with a duration that overlapped the beginning of pregnancy. Prevalence of opioids use was calculated for all pregnancies, according to pregnancy outcome, trimester of exposure, and individual opioids. The duration of opioid use during pregnancy was analyzed according to 8 categories based on cumulative duration (< 90 days vs. ≥90 days), duration of action (short-acting vs. long-acting) and strength of the opioid (weak vs. strong).

Results

Of 442,079 eligible pregnancies, 20,921 (4.7%) were exposed to opioids. Among pregnancies ending with deliveries (n = 249,234), 5.4% were exposed to opioids; the prevalence increased by 40.3% from 3.9% in 1998 to 5.5% in 2015, more specifically a significant increase in the second and third trimesters of pregnancy. Weak opioid, codeine was the most commonly dispensed opioid (70% of all dispensed opioids), followed by strong opioid, hydromorphone (11%), morphine (10%), and oxycodone (5%). The prevalence of codeine use decreased by 47% from 4.3% in 2005 to 2.3% in 2015, accompanied by an increased use of strong opioid, morphine (0.029 to 1.41%), hydromorphone (0.115 to 1.08%) and oxycodone (0.022 to 0.44%), from 1998 to 2015. The average durations of opioid exposure were significantly longer among pregnancies exposed to strong opioid as compared to weak opioid regardless of the cumulative duration or duration of action (P < 0.05).

Conclusions

Given the differences in the safety profile between strong opioids and the major weak opioid codeine, the increased use of strong opioids during pregnancy with longer treatment duration raises public health concerns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04270-x.

Maternal Complications and Prescription Opioid Exposure During Pregnancy: Using Marginal Structural Models

INTRODUCTION

Prescription opioids are frequently used for pain management in pregnancy. Studies examining perinatal complications in mothers who received prescription opioids during pregnancy are still limited.

OBJECTIVES

The aim of this study was to assess the association of prescription opioid use and maternal pregnancy and obstetric complications.

METHODS

This retrospective cohort study with the Rhode Island (RI) Medicaid claims data linked to vital statistics throughout 2008-2015 included pregnant women aged 12-55 years with one or multiple live births. Women were excluded if they had cancer, opioid use disorder, or opioid dispensing prior to but not during pregnancy. Main outcomes included adverse pregnancy and obstetric complications. Marginal Structural Cox Models with time-varying exposure and covariates were applied to control for baseline and time-varying covariates. Analyses were conducted for outcomes that occurred 1 week after opioid exposure (primary) or within the same week as exposure (secondary). Sensitivity studies were conducted to assess the effects of different doses and individual opioids.

RESULTS

Of 9823 eligible mothers, 545 (5.5%) filled one or more prescription opioid during pregnancy. Compared with those unexposed, no significant risk was observed in primary analyses, while in secondary analyses opioid-exposed mothers were associated with an increased risk of cesarean antepartum depression (HR 3.19; 95% CI 1.22-8.33), and cardiac events (HR 9.44; 95% CI 1.19-74.83). In sensitivity analyses, results are more prominent in high dose exposure and are consistent for individual opioids.

CONCLUSIONS

Prescription opioid use during pregnancy is associated with an increased risk of maternal complications.

Association of Timing and Duration of Prenatal Analgesic Opioid Exposure With Attention-Deficit/Hyperactivity Disorder in Children

IMPORTANCE

Prior studies have reported that the use of illicit opioids during pregnancy is associated with increased risk of attention-deficit/hyperactivity disorder (ADHD) in offspring; however, evidence regarding the association of analgesic opioids is limited.

OBJECTIVE

To examine the association of timing and duration of prenatal analgesic opioid exposure with ADHD in children.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study uses data from the Norwegian Mother, Father and Child Cohort study (1999-2008), a nationwide birth cohort study linked to national health registries, with a mean (SD) follow-up of 10.8 (2.2) years. A total of 73 784 live-born singleton children born to 62 013 mothers who reported a pain-related condition before and/or during pregnancy were included, with 2 comparator groups: (1) mothers who did not use any opioids and (2) mothers who used opioids before pregnancy only. Data were analyzed from June to December 2020.

EXPOSURES

Maternal self-report of analgesic opioid use during pregnancy, by timing (early and middle and/or late) and duration (≥5 weeks vs ≤4 weeks).

MAIN OUTCOMES AND MEASURES

Diagnosis of ADHD or filled prescription for ADHD medication in children and symptoms of ADHD at child age 5 years, measured by Conners' Parent Rating Scale-Revised. Inverse probability of treatment weights were used to control for measured confounding. Cox regression was used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

The analyses of ADHD diagnosis and ADHD symptoms included 73 480 children (35 996 [49.0%] girls; mean [SD] maternal age, 30.0 [4.6] years) and 31 270 children (15 377 [49.2%] girls; mean [SD] maternal age, 30.5 [4.4] years), respectively. Overall, 1726 children in the ADHD diagnosis sample (2.3%) and 667 children in the ADHD symptom sample (2.1%) were exposed to an analgesic opioid at least once during gestation. No associations between timing of prenatal analgesic opioid exposure and ADHD diagnosis or symptoms was found. Exposure for 5 or more weeks was associated with an increased risk of ADHD diagnosis (HR, 1.60, 95% CI, 1.04-2.47) compared with exposure for 4 weeks or less; however, there was no such association for the risk of ADHD symptoms.

CONCLUSIONS AND RELEVANCE

In this cohort study, a slightly elevated risk of ADHD diagnosis after prenatal analgesic opioid exposure for 5 or more weeks was found compared with exposure for 4 weeks or less. This result may be driven by longer duration of use; however, the role of residual or unmeasured confounding cannot be excluded. This finding needs to be replicated in other studies.

A Clinical Trial of a Program for Pain Management and Opioid Reduction During Pregnancy

A substantial proportion of pregnant women use prescription opioids. However, the lack of efficacy of chronic prescription opioid use for pain, combined with an increased risk of these medications in general and during pregnancy, suggests that the risks of these medications may outweigh the benefits of continued use. Though research has not evaluated non-pharmacological approaches to treat chronic pain during pregnancy, research conducted with the general population outside of pregnancy suggests that cognitive behavioral therapy (CBT) is an effective, non-pharmacological treatment. Therefore, the purpose of this study was to evaluate the effectiveness of CBT for chronic pain paired with shared decision-making for prescription opioid dose reduction among pregnant women with prescription opioid misuse. The study was an open-label, 8-week clinical trial of CBT for chronic pain and shared decision-making for prescription opioid dose reduction. Participants included a clinical sample of 20 pregnant women between the ages of 18 and 45 years who were misusing opioids but did not meet DSM-IV criteria for an opioid use disorder or other substance use disorder. Compared to baseline, at 8 weeks, participants had significant reductions in average prescription opioid morphine equivalent dose, prescription opioid misuse, worst pain ratings, and pain interference in general activity and at work. They did not report improvement in other pain ratings or areas of functioning. This study provides valuable information regarding the preliminary efficacy of CBT for chronic pain paired with shared decision-making among pregnant women misusing prescription opioids. ClinicalTrials.gov: NCT02804152.

Adapting an Evidence-Based Home Visiting Intervention for Mothers With Opioid Dependence: Modified Attachment and Biobehavioral Catch-up

Infants born to mothers who are dependent on opioids often have difficulty regulating behavior and physiology at birth. Without sensitive maternal care, these infants are at risk for ongoing problems with self-regulation. Mothers who are dependent on opioids may experience challenges related to their substance use (e.g., unsupportive and/or risky environment, impulse control and reward system problems) that increase the likelihood of insensitive parenting in the absence of effective intervention. In this paper, we describe a home-visiting intervention we have adapted to enhance sensitive, responsive caregiving tailored to the specific needs of mothers with opioid dependence. The original intervention, Attachment and Biobehavioral Catch-up (ABC), was designed for mothers of infants aged 6-24 months who were exposed to early adversity. ABC has been shown to enhance sensitive parenting as well as children's behavioral and biological functioning, with positive outcomes extending into at least middle childhood. Mothers who are opioid dependent need earlier support than provided by ABC because opioid-exposed infants are often vulnerable at birth. The adapted intervention (modified ABC or mABC) includes one prenatal session and one early postnatal session, followed by 10 sessions every 2-3 weeks. In the initial two sessions in particular, mothers are helped to anticipate the challenges of caring for a baby who may be difficult to soothe while nonetheless providing sensitive care. mABC is intended to help mothers see the importance of responding sensitively so as to help infants overcome the developmental risks associated with opioid exposure. Additionally, mABC is structured to support mothers with the challenges of early parenting, especially if the mother herself was not parented sensitively. Throughout, the focus is on helping the mother nurture the distressed infant, attend to the infant's signals, and avoid behaving in overstimulating or intrusive ways. Case examples are presented that highlight both the challenges of working with this population as well as the gains made by mothers.

Prevalence of prescription opioid use during pregnancy in eight US health plans during 2001-2014

PURPOSE

To estimate prevalence of prescription opioid use during pregnancy in eight US health plans during 2001-2014.

METHODS

We conducted a cohort study of singleton live birth deliveries. Maternal characteristics were ascertained from health plan and/or birth certificate data and opioids dispensed during pregnancy from health plan pharmacy records. Prevalence of prescription opioid use during pregnancy was calculated for any use, cumulative days of use, and number of dispensings.

RESULTS

We examined prevalence of prescription opioid use during pregnancy in each health plan. Tennessee Medicaid had appreciably greater prevalence of use compared to the seven other health plans. Thus, results for the two groups were reported separately. In the seven health plans (n = 587 093 deliveries), prevalence of use during pregnancy was relatively stable at 9%-11% throughout 2001-2014. In Tennessee Medicaid (n = 256 724 deliveries), prevalence increased from 29% in 2001 to a peak of 36%-37% in 2004-2010, and then declined to 28% in 2014. Use for ≥30 days during pregnancy was stable at 1% in the seven health plans and increased from 2% to 7% in Tennessee Medicaid during 2001-2014. Receipt of ≥5 opioid dispensings during pregnancy increased in the seven health plans (0.3%-0.6%) and Tennessee Medicaid (3%-5%) during 2001-2014.

CONCLUSION

During 2001-2014, prescription opioid use during pregnancy was more common in Tennessee Medicaid (peak prevalence in late 2000s) compared to the seven health plans (relatively stable prevalence). Although a small percentage of women had opioid use during pregnancy for ≥30 days or ≥ 5 dispensings, they represent thousands of women during 2001-2014.

Association Between Prenatal Opioid Exposure and Neurodevelopmental Outcomes in Early Childhood: A Retrospective Cohort Study

INTRODUCTION

Several studies have reported increasing prevalence of prescription opioid use among pregnant women. However, little is known regarding the effects of maternal opioid use on neurodevelopmental disorders in early childhood in pregnant women with no evidence of opioid use disorders or drug dependence.

OBJECTIVE

The aim of this study was to quantify the association between prenatal opioid exposure from maternal prescription use and neurodevelopmental outcomes in early childhood.

METHODS

This retrospective study included pregnant women aged 12-55 years and their live-birth infants born from 2010 to 2012 present in Optum's deidentified Clinformatics® Data Mart database. Eligible infants born to mothers without opioid use disorders or drug dependence were followed till occurrence of neurodevelopmental disorders, loss to follow-up, or study end (December 31, 2017), whichever came first. Propensity score by fine stratification was applied to adjust for confounding by demographic characteristics, obstetric characteristics, maternal comorbid mental and pain conditions, and measures of burden of illnesses and to obtain adjusted hazard ratios (HR) and 95% confidence intervals (CI). Exposed and unexposed infants were compared on the incidence of neurodevelopmental disorders.

RESULTS

Of 24,910 newborns, 7.6% (1899) were prenatally exposed to prescription opioids. Overall, 1562 children were diagnosed with neurodevelopmental disorders, with crude incidence rates of 2.9 per 100 person-years in exposed children versus 2.5 per 100 person-years in unexposed children. After adjustment, we observed no association between fetal opioid exposure and the risk of neurodevelopmental disorders (HR 1.10; 95% CI 0.92-1.32). However, increased risk of neurodevelopmental disorders were observed in children with longer cumulative exposure duration (HR 1.70; 95% CI 1.05-2.96) or high cumulative opioid doses (HR 1.22; 95% CI 1.01-1.54).

CONCLUSION AND RELEVANCE

In pregnant women without opioid use disorders or drug dependence, maternal opioid use was not associated with increased risk of neurodevelopmental disorders in early childhood. However, increased risks of early neurodevelopmental disorders were observed in children born to women receiving prescription opioids for longer duration and at higher doses during pregnancy.

Maternal Methadone Destabilizes Neonatal Breathing and Desensitizes Neonates to Opioid-Induced Respiratory Frequency Depression

Pregnant women and developing infants are understudied populations in the opioid crisis, despite the rise in opioid use during pregnancy. Maternal opioid use results in diverse negative outcomes for the fetus/newborn, including death; however, the effects of perinatal (maternal and neonatal) opioids on developing respiratory circuitry are not well understood. Given the profound depressive effects of opioids on central respiratory networks controlling breathing, we tested the hypothesis that perinatal opioid exposure impairs respiratory neural circuitry, creating breathing instability. Our data demonstrate maternal opioids increase apneas and destabilize neonatal breathing. Maternal opioids also blunted opioid-induced respiratory frequency depression acutely in neonates; a unique finding since adult respiratory circuity does not desensitize to opioids. This desensitization normalized rapidly between postnatal days 1 and 2 (P1 and P2), the same age quantal slowing emerged in respiratory rhythm. These data suggest significant reorganization of respiratory rhythm generating circuits at P1-2, the same time as the preBötzinger Complex (key site of respiratory rhythm generation) becomes the dominant respiratory rhythm generator. Thus, these studies provide critical insight relevant to the normal developmental trajectory of respiratory circuits and suggest changes to mutual coupling between respiratory oscillators, while also highlighting how maternal opioids alter these developing circuits. In conclusion, the results presented demonstrate neurorespiratory disruption by maternal opioids and blunted opioid-induced respiratory frequency depression with neonatal opioids, which will be important for understanding and treating the increasing population of neonates exposed to gestational opioids.

Sex Differences in Early Cognitive Development After Prenatal Exposure to Opioids

Objective

Prenatal opioid exposure has been linked with impaired cognitive development, with boys potentially at elevated risk. In the present study, we examined cognitive and language development of children prenatally exposed to opioids, with an additional focus on sex differences.

Methods

A sample of 378 children (n = 194 girls and n = 184 boys) aged 1.2–42.8 months was drawn from the Danish Family Outpatient Clinic database. Developmental outcomes were assessed using the Bayley-III cognitive and language scales, and substance exposure was determined with urine screening and/or verbal report. Children exposed to opioids (n = 94) were compared to children with no prenatal substance exposure (n = 38), and children exposed to alcohol (n = 131) or tobacco (n = 115). Group and sex differences were investigated with separate linear mixed models for each Bayley scale, controlling for concurrent cannabis exposure.

Results

There were significantly reduced scores in opioid-exposed boys compared to boys with no prenatal substance exposure, but no difference between opioid-exposed and nonexposed girls. Additionally, alcohol-exposed boys had lower cognitive scores than nonexposed boys, and alcohol-exposed girls had lower scores on both scales compared to opioid-exposed girls. There were otherwise no significant differences according to group, sex, or scale.

Conclusions

The present findings indicate poorer cognitive and language development in boys after prenatal opioid exposure. As academic performance is rooted in cognitive functioning, long-term follow-up might be necessary for exposed children.

Human Fetal Liver Metabolism of Oxycodone Is Mediated by CYP3A7

Oxycodone is an opioid analgesic that is commonly prescribed to pregnant women to treat moderate-to-severe pain. It has been shown to cross the placenta and distribute to the fetus. Oxycodone is mainly metabolized by CYP3A4 in the adult liver. Since CYP3A7 is abundantly expressed in the fetal liver and has overlapping substrate specificity with CYP3A4, we hypothesized that the fetal liver may significantly limit fetal exposure to oxycodone. This study showed that oxycodone is metabolized by CYP3A7 to noroxycodone in fetal liver microsomes (FLMs). The measured CYP3A7 expression was 191-409 pmol/mg protein in 14 FLMs, and an intersystem extrapolation factor (ISEF) for CYP3A7 was 0.016-0.066 in the panel of fetal livers using 6β-OH-testosterone formation as the probe reaction. Noroxycodone formation in the fetal liver was predicted from formation rate by recombinant CYP3A7, CYP3A7 expression level and the established ISEF value with average fold error of 1.25. Based on the intrinsic clearance of oxycodone measured in FLM, the fetal hepatic clearance (CLh) at term was predicted to be 495 (range: 66.4-936) μL/min, a value that is > 99% lower than the predicted adult liver CLh. The predicted fetal hepatic extraction ratio was 0.0019 (range: 0.00003-0.0036). These results suggest that fetal liver metabolism does not quantitatively contribute to the total systemic clearance of oxycodone in pregnant women nor does it provide a barrier for limiting fetal exposure to oxycodone. Additionally, since CYP3A7 forms noroxycodone, an inactive metabolite, the metabolism in the fetal liver is unlikely to affect fetal opioid activity.

Temporal trends in rates of opioid misuse among delivery-related hospitalizations in North Carolina from 2000 to 2014

Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a log_e-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16-1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9-381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2-1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids.

Prenatal Opioid Exposure Enhances Responsiveness to Future Drug Reward and Alters Sensitivity to Pain: A Review of Preclinical Models and Contributing Mechanisms

The opioid crisis has resulted in an unprecedented number of neonates born with prenatal opioid exposure (POE); however, the long-term effects of POE on offspring behavior and neurodevelopment remain relatively unknown. The advantages and disadvantages of the various preclinical POE models developed over the last several decades are discussed in the context of clinical and translational relevance. Although considerable and important variability exists among preclinical models of POE, the examination of these preclinical models has revealed that opioid exposure during the prenatal period contributes to maladaptive behavioral development as offspring mature including an altered responsiveness to rewarding drugs and increased pain response. The present review summarizes key findings demonstrating the impact of POE on offspring drug self-administration (SA), drug consumption, the reinforcing properties of drugs, drug tolerance, and other reward-related behaviors such as hypersensitivity to pain. Potential underlying molecular mechanisms which may contribute to this enhanced addictive phenotype in POE offspring are further discussed with special attention given to key brain regions associated with reward including the striatum, prefrontal cortex (PFC), ventral tegmental area (VTA), hippocampus, and amygdala. Improvements in preclinical models and further areas of study are also identified which may advance the translational value of findings and help address the growing problem of POE in clinical populations.

Social and legal implications of urine drug screen analysis in the neonate: A case of suspected specimen mishandling

BACKGROUND

The legal implications associated with illicit drug use during pregnancy are significant, as providers are required to notify child protective services when a drug-exposed infant is identified.

CASE REPORT

The case presented involves possible specimen mishandling in two infants at risk for in utero drug exposure and describes alternative methodologies available to confirm specimen identity.

CONCLUSIONS

It is critical that institutions establish and adhere to stringent procedures when screening newborns.

Association of Pregnancy and Insurance Status With Treatment Access for Opioid Use Disorder

IMPORTANCE

Medications for opioid use disorder, including buprenorphine hydrochloride and methadone hydrochloride, are highly effective at improving outcomes for individuals with the disorder. For pregnant women, use of these medications also improves pregnancy outcomes, including the risk of preterm birth. Despite the known benefits of medications for opioid use disorder, many pregnant and nonpregnant women with the disorder are not receiving them.

OBJECTIVE

To determine whether pregnancy and insurance status are associated with a woman's ability to obtain an appointment with an opioid use disorder treatment clinician.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study with random assignment of clinicians and simulated-patient callers (performed in "secret shopper" format), outpatient clinics that provide buprenorphine and methadone were randomly selected from publicly available treatment lists in 10 US states (selected for variability in opioid-related outcomes and policies) from March 7 to September 5, 2019. Pregnant vs nonpregnant woman and private vs public insurance assigned randomly to callers to create unique patient profiles. Simulated patients called the clinics posing as pregnant or nonpregnant women to obtain an initial appointment with a clinician.

MAIN OUTCOMES AND MEASURES

Appointment scheduling, wait time, and out-of-pocket costs.

RESULTS

A total of 10 871 unique patient profiles were assigned to 6324 clinicians. Among all women, 2312 of 3420 (67.6%) received an appointment with a clinician who prescribed buprenorphine, with lower rates among pregnant vs nonpregnant callers (1055 of 1718 [61.4%] vs 1257 of 1702 [73.9%]; relative risk, 0.83; 95% CI, 0.79-0.87). For clinicians who prescribed methadone, there was no difference in appointment access for pregnant vs nonpregnant callers (240 of 271 [88.6%] vs 237 of 265 [89.4%]; relative risk, 0.99; 95% CI, 0.93-1.05). Insurance was frequently not accepted, with 894 of 3420 buprenorphine-waivered prescribers (26.1%) and 174 of 536 opioid treatment programs (32.5%) granting appointments only when patients agreed to pay cash. Median wait times did not differ between pregnant and nonpregnant callers among buprenorphine prescribers (3 days [interquartile range, 1-7 days] vs 3 days [interquartile range, 1-7 days]; P = .43) but did differ among methadone prescribers (1 day [interquartile range, 1-4 days] vs 2 days [interquartile range, 1-6 days]; P = .049). For patients agreeing to pay cash, the median out-of-pocket costs for initial appointments were $250 (interquartile range, $155-$300) at buprenorphine prescribers and $34 (interquartile range, $15-$120) at methadone prescribers.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study with random assignment of clinicians and simulated-patient callers, many women, especially pregnant women, faced barriers to accessing treatment. Given the high out-of-pocket costs and lack of acceptance of insurance among many clinicians, access to affordable opioid use disorder treatment is a significant concern.

Opioid exposure in newborns: lessons learned from fetal alcohol spectrum disorder

The increasing incidence of opioid-exposed pregnancies in the United States is a concerning public health challenge. Analysis of the public health responses to prenatal alcohol exposure may inform future prevention and treatment strategies. Behavioral interventions, improved screening, and prenatal education may be effective measures to reduce prenatal exposure to opioids. Medicaid coverage should be expanded to cover substance misuse treatments for pregnant women.

In utero exposure to analgesic opioids and language development in 5-year old children

PURPOSE

An increasing consumption of opioids has been reported. The primary aim of the present study was follow-up of neurocognitive development in children exposed to analgesic opioids during pregnancy, using three different validated instruments to assess language and communication development at 5 years.

METHODS

The Norwegian Mother and Child Cohort Study (MoBa) prospectively included pregnant women 1999 to 2008. Participants reported medication use at pregnancy week 17/18 and 30, and 6 months after birth. Children's language competence and communication skills at 5 years were reported by mothers on three different validated scales; The Ages and Stages Questionnaire (ASQ), The Speech and Language Assessment Scale (SLAS) and The Twenty Statements about Language-Related Difficulties list (Language20Q).

RESULTS

A total of 27 428 women with 33 407 singleton pregnancies were included. Use of analgesic opioids was reported in 584 pregnancies (1.7%). No associations between opioid use and lower language competence or communication skills were found. For ASQ, the OR of being in the lowest category vs the group with maximum mean score was 0.82 (95%CI 0.57, 1.17), for SLAS the OR of scoring worse than typical for age vs better than typical for age was 0.84 (0.61, 1.17) in children exposed to opioids in utero. For Language20Q using the best performance category as reference, the OR of scoring in the lower performance category was 0.57 (0.35, 0.91) with exposure to opioids.

CONCLUSION

Use of analgesic opioids in pregnant women does not seem to negatively affect language development or communication skills in children at 5 years.

Prenatal opioid exposure: The next neonatal neuroinflammatory disease

The rates of opioid use disorder during pregnancy have more than quadrupled in the last decade, resulting in numerous infants suffering exposure to opioids during the perinatal period, a critical period of central nervous system (CNS) development. Despite increasing use, the characterization and definition of the molecular and cellular mechanisms of the long-term neurodevelopmental impacts of opioid exposure commencing in utero remains incomplete. Thus, in consideration of the looming public health crisis stemming from the multitude of infants with prenatal opioid exposure entering school age, we undertook an investigation of the effects of perinatal methadone exposure in a novel preclinical model. Specifically, we examined the effects of opioids on the developing brain to elucidate mechanisms of putative neural cell injury, to identify diagnostic biomarkers and to guide clinical studies of outcome and follow-up. We hypothesized that methadone would induce a pronounced inflammatory profile in both dams and their pups, and be associated with immune system dysfunction, sustained CNS injury, and altered cognition and executive function into adulthood. This investigation was conducted using a combination of cellular, molecular, biochemical, and clinically translatable biomarker, imaging and cognitive assessment platforms. Data reveal that perinatal methadone exposure increases inflammatory cytokines in the neonatal peripheral circulation, and reprograms and primes the immune system through sustained peripheral immune hyperreactivity. In the brain, perinatal methadone exposure not only increases chemokines and cytokines throughout a crucial developmental period, but also alters microglia morphology consistent with activation, and upregulates TLR4 and MyD88 mRNA. This increase in neuroinflammation coincides with reduced myelin basic protein and altered neurofilament expression, as well as reduced structural coherence and significantly decreased fractional anisotropy on diffusion tensor imaging. In addition to this microstructural brain injury, adult rats exposed to methadone in the perinatal period have significant impairment in associative learning and executive control as assessed using touchscreen technology. Collectively, these data reveal a distinct systemic and neuroinflammatory signature associated with prenatal methadone exposure, suggestive of an altered CNS microenvironment, dysregulated developmental homeostasis, complex concurrent neural injury, and imaging and cognitive findings consistent with clinical literature. Further investigation is required to define appropriate therapies targeted at the neural injury and improve the long-term outcomes for this exceedingly vulnerable patient population.

Co-use of alcohol, tobacco, and licit and illicit controlled substances among pregnant and non-pregnant women in the United States: Findings from 2006 to 2014 National Survey on Drug Use and Health (NSDUH) data

BACKGROUND

The use, misuse and co-use of alcohol, cannabis, tobacco, and other licit and illicit controlled substances has increased in past decades leading to higher rates of morbidity, overdose, and mortality in women of reproductive age. Co-use compounds the adverse health effects of substance use compared to single-use of similar substances. Little is known about the full range of substance combinations used by pregnant and non-pregnant women. We sought to describe patterns of co-use of alcohol, tobacco, and controlled substances, and examine correlates of co-use in a nationally-representative sample of women.

METHODS

Cross-sectional study using self-reported survey data from 2006 to 2014 for women ages 18-49 years (N = 160,371) in National Survey on Drug Use and Health data. We use weighted proportions and 95% confidence intervals (CI) to report differences in substance use patterns in pregnant and non-pregnant women. Multivariate logistic regression models assessed association between characteristics and type of substance use pattern.

RESULTS

Prevalence of substance co-use among pregnant women is 5.1% and among non-pregnant women is 23.6%. Nearly all of the most frequent co-use patterns included alcohol, cannabis, or tobacco. Determinants of co-use among pregnant women included: younger age (18-25 years) compared to ≥ 26 years [AOR (95% CI): 1.81 (1.18, 2.80)]; and past year history of substance use [AOR 5.42 (3.59, 8.20)].

CONCLUSIONS

Co-use of several substances, including and especially of tobacco, alcohol and cannabis, persists among pregnant women in the United States. Efforts that aim to improve maternal and child health should address the complexity of substance use during pregnancy, including and beyond opioids.

Research and policy priorities for addressing prenatal exposure to opioids in Alaska

The current opioid crisis in Alaska and the USA will negatively affect the health and wellbeing of future generations. The increasing number of infants born with neonatal opioid withdrawal syndrome (NOWS) has had a profound impact on families, health care providers and the child welfare system. This manuscript summarises the main themes of a Symposium held in Anchorage, Alaska with health care providers, researchers, elders and public health officials that focused on identifying emerging challenges, trends and potential solutions to address the increasing number of infants and children affected by maternal opioid use. Five areas of importance for research and policy development that would direct improvement in the care of infants with NOWS in Alaska are outlined with the goal of supporting a research agenda on opioid misuse and child health across the circumpolar north. Abbreviations: NOWS - neonatal opioid withdrawal syndrome; NAS - neonatal abstinence syndrome; MAT - medication-assisted treatment; NICU - neonatal intensive care unit; OATs - opioid agonist treatments; OCS - office of children's services; ANTHC - Alaska Native Tribal Health Consortium; OUD - opioid use disorder; SBIRT - screening, brief intervention and referral to treatment; ISPCTN - IDeA States Pediatric Clinical Trials Network; NIH - National Institutes of Health; ANMC - Alaska Native Medical Center; DHSS - Department of Health and Social Services; AAPP - All Alaska Pediatric Partnership.

Maternal prescribed opioid analgesic use during pregnancy and associations with adverse birth outcomes: A population-based study

BACKGROUND

Published research on prescribed opioid analgesic (POA) use during pregnancy and birth outcomes is limited in scope and has not adequately adjusted for potential confounding factors. To help address these gaps, we estimated associations between maternal POAs during pregnancy and two adverse birth outcomes using a large population-based dataset, multiple definitions of POA exposure, and several methods to evaluate the influence of both measured and unmeasured confounding factors.

METHODS AND FINDINGS

We obtained data by linking information from several Swedish registers and conducted a retrospective cohort study on a population-based sample of 620,458 Swedish births occurring between 2007 and 2013 (48.6% female; 44.4% firstborn). We evaluated associations between prenatal POA exposure and risk for preterm birth (PTB; <37 gestational weeks) and small for gestational age (SGA; birth weight 2 standard deviations below the expected weight for gestational age or lower). We evaluated the influence of confounding by adjusting for a wide range of measured covariates while comparing exposed and unexposed infants. Additionally, we adjusted for unmeasured confounding factors by using several advanced epidemiological designs. Infants exposed to POAs anytime during pregnancy were at increased risk for PTB compared with unexposed infants (6.4% exposed versus 4.4% unexposed; adjusted odds ratio [OR] = 1.38, 95% confidence interval [CI] 1.31-1.45, p < 0.001). This association was attenuated when we compared POA-exposed infants with acetaminophen-exposed infants (OR = 1.18, 95% CI 1.07-1.30, p < 0.001), infants born to women who used POAs before pregnancy only (OR = 1.05, 95% CI 0.96-1.14, p = 0.27), and unexposed siblings (OR = 0.99, 95% CI 0.85-1.14, p = 0.92). We also evaluated associations with short-term versus persistent POA use during pregnancy and observed a similar pattern of results, although the magnitudes of associations with persistent exposure were larger than associations with any use or short-term use. Although short-term use was not associated with SGA (adjusted ORsingle-trimester = 0.95, 95% CI 0.87-1.04, p = 0.29), persistent use was associated with increased risk for SGA (adjusted ORmultiple-trimester = 1.40, 95% CI 1.17-1.67, p < 0.001) compared with unexposed infants. The association with persistent exposure was attenuated when we used alternative comparison groups (e.g., sibling comparison OR = 1.22, 95% CI 0.60-2.48, p = 0.58). Of note, our study had limitations, including potential bias from exposure misclassification, an inability to adjust for all sources of confounding, and uncertainty regarding generalizability to countries outside of Sweden.

CONCLUSIONS

Our results suggested that observed associations between POA use during pregnancy and risk of PTB and SGA were largely due to unmeasured confounding factors, although we could not rule out small independent associations, particularly for persistent POA use during pregnancy.

Prescription and Other Medication Use in Pregnancy

OBJECTIVE

To characterize prescription and other medication use in a geographically and ethnically diverse cohort of women in their first pregnancy.

METHODS

In a prospective, longitudinal cohort study of nulliparous women followed through pregnancy from the first trimester, medication use was chronicled longitudinally throughout pregnancy. Structured questions and aids were used to capture all medications taken as well as reasons they were taken. Total counts of all medications taken including number in each category and class were captured. Additionally, reasons the medications were taken were recorded. Trends in medications taken across pregnancy and in the first trimester were determined.

RESULTS

Of the 9,546 study participants, 9,272 (97.1%) women took at least one medication during pregnancy with 9,139 (95.7%) taking a medication in the first trimester. Polypharmacy, defined as taking at least five medications, occurred in 2,915 (30.5%) women. Excluding vitamins, supplements, and vaccines, 73.4% of women took a medication during pregnancy with 55.1% taking one in the first trimester. The categories of drugs taken in pregnancy and in the first trimester include the following: gastrointestinal or antiemetic agents (34.3%, 19.5%), antibiotics (25.5%, 12.6%), and analgesics (23.7%, 15.6%, which includes 3.6%; 1.4% taking an opioid pain medication).

CONCLUSION

In this geographically and ethnically diverse cohort of nulliparous pregnant women, medication use was nearly universal and polypharmacy was common.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01322529.

Medication Use and Pain Management in Pregnancy: A Critical Review

BACKGROUND

Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence-based recommendations for managing pain in pregnancy.

METHODS

A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases.

RESULTS

Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues.

CONCLUSIONS

Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.

Chronic Pain Prevalence and Exposures during Pregnancy

Pregnant women with chronic pain present a unique clinical challenge for both chronic pain and obstetrical providers, and clinical guidelines do not exist. The present study describes the prevalence and management of chronic pain during pregnancy in a perinatal mood disorder clinic. A retrospective chart review of pregnant women who presented to the Women's Mental Health Program at the University of Arkansas for Medical Sciences (UAMS) for an initial evaluation from July 2013 to June 2016 was conducted to obtain demographic and medical information, including pharmacological exposures. Data are described using the mean and standard deviation for continuous data and frequency for categorical data. Pain complaints and medications are presented as counts and percentages. Differences between women with and without chronic pain were assessed by t-tests for continuous variables and chi-square analysis for categorical variables. Of the 156 pregnant women, chronic pain conditions were reported by 44 (28.2%). The most common chronic pain complaints included neck and/or back pain (34.1%) and headaches (31.8%). Of subjects with chronic pain, 95.5% were taking at least one prescription medication (mean = 2.6 ± 2.1, range of 0-10). Acetaminophen (43.2%) and opioids (43.2%) were the most common. The complexity of managing maternal benefits of treatment with the risks of fetal exposures presents a uniquely challenging clinical scenario for healthcare providers.

Use of opioids during pregnancy and effects of pregnancy outcomes

PURPOSE

To evaluate the use of opioids in pregnant primiparous women and study the effect of opioid use on maternal and offspring delivery outcomes.

METHODS

The study cohort (N = 6231) consists of all primiparous women with a Finnish background who delivered a singleton between 2009 and 2015 in the city of Vantaa, Finland. Data on births, maternal characteristics, pregnancy outcomes, and purchases of prescription drugs were obtained from National Health Registers.

RESULTS

Of the primiparous women, 5.1% used opioids during pregnancy. Of these, 95.9% used codeine. No differences were observed in purchases of opioids between the different trimesters but more women purchased opioids as pregnancy progressed (.002). Users of opioids more often also purchased other prescription drugs compared with non-users of opioids, 89% versus 58% (P < .001); age, smoking, education, and body mass index adjusted odds ratio 5.66 (95% confidence interval 3.96 to 8.09). Caesarean sections were more common in users of opioids than in non-users, 28.3% versus 21.9% (.007). Before the age of 7 days, the offspring of users of opioids more often needed respirator treatment compared with the offspring of non-users, 3.1% versus 1.6% (.044).

CONCLUSIONS

One out of 20 pregnant women used opioids. Use of opioids during pregnancy was associated with the risk for deliveries by caesarean sections and need for respiratory treatment among the offspring during the first week of life. Further safety evaluations are needed.